UNIVERSITY OF CONNECTICUT Upward Bound/ConnCAP Program 2011 Student Application

Applicants Name: Dear Applicant: Thank you for applying to the University of Connecticut Upward Bound Program. Upward Bound is designed to generate in students the skills and motivation necessary for success in education beyond secondary school. To learn more about the program and the eligibility criteria please refer to the back of this application and see About UConns Upward Bound/ConnCAP Program for more information. This application is used to determine student eligibility for admission into the program. All information requested is according to federal and state guidelines. All information submitted is used for program participation only. Please do not leave questions unanswered. If you or your parents/guardians have any questions or need any help with this application please call us at (860) 486-3549 or 1-(800) 8396869. INSTRUCTIONS: This application consists of the following sections and attachments: 1. Student Information 2. Parent/Guardian Information 3. Program Required Forms and Documents Report Cards/Transcript Release Form Teacher Recommendation Form (English, Math or Science) Guidance Counselor Recommendation Form Most Recent Report Card CMT Test Scores Income Tax Form or Income Documentation for 2010 (Income verification is mandatory. If not enclosed, we will request this documentation later) Applications can also be printed on-line at www.cap.uconn.edu/ub.htm APPLICATION DEADLINE: FEBRUARY 14, 2011 PLEASE GIVE THIS COMPLETED APPLICATION TO YOUR GUIDANCE COUNSELOR OR MAIL IT TO: Susana M. Ulloa, Director University of Connecticut Upward Bound/ConnCAP Program 368 Fairfield Way, U-2170 Storrs, CT 06269-2170 Office Use Only: Rec: _________ S.I.: High School: Grade:

About UConns Upward Bound/ConnCAP Program What is the Upward Bound/ConnCAP Program? The Upward Bound/ConnCAP Program at the University of Connecticut has been serving high school students for 44 years. Students are selected to participate in Upward Bound/ConnCAP at the end of the ninth grade and continue in the program until high school graduation. The programs main objectives are: 1) to ensure successful high school graduation for its participants; 2) to assist students in applying to and enrolling in a college of their choice with the ultimate goal of college graduation. Who is eligible for participation in the program? Federal and state guidelines stipulate that students must meet either or both of the following criteria 1) be first generation to college (neither parent nor guardian has a degree from a four-year college); or 2) the family must meet federal income guidelines and be considered low-incomeparents/guardians income documentation will be requested in order to complete this application. Also, students must have academic need as determined by report cards, test scores, etc. Eligible students are selected from the following target cities and high schools: Hartford (Bulkeley and Hartford Public; New Haven (Hillhouse and Wilbur Cross); Windham (Windham) How much does the program cost? If we put a price tag the program costs approximately $5,900.00 per student, each year. Parents and guardians of admitted students do not pay to participate in the program; we receive funds from the U.S. Department of Education, the State of Connecticut Department of Higher Education, and the University of Connecticut. To stay active in the program students must attend the summer and academic year components. What happens after students apply? We will carefully review each application, set up an interview at the students high school, and we will let you know about your acceptance status by May or before. What are the requirements for participation? Once admitted, students and their parents/guardians must attend an orientation at UConn. We expect students stay active in the program by attending weekly meetings and program activities, maintaining a good academic standing, and following the programs rules and regulations as stated in the Student and Parent/Guardian Handbook. What is the summer component? Students attend summer sessions at the University of Connecticut following their ninth, tenth, and eleventh grades in school. The summer curriculum seeks to prepare students for the academic challenges they will encounter during the forthcoming academic year. Classes are intensive and academically rigorous, with a significant amount of homework each evening. These intensive six-week residential programs are designed to advance students' academic skill levels in literature, composition, a foreign language, science and mathematics. Students also participate in a variety of extracurricular activities that promote academic and personal growth. What is the academic year component? The Academic Year Component seeks to provide students with academic enrichment seminars and personal development. The academic year includes the following activities: Parental/Guardian component Weekly after school meetings and monitoring Academic enrichment workshops Assistance with career, college, and financial aid process In-state and out-of-state college trips Tutoring services and academic advising Cultural and social activities Career awareness conferences/workshops

Other questions? Please feel free to call us at 1-(800) 839-6869 or you can visit us at www.cap.uconn.edu
UConn Upward Bound/ConnCAP Program-2011 Student Application

UConn Upward Bound/ConnCAP Program-2011 Student Application

Section 1. Student Information

Please complete all questions fully. Leaving questions or sections unanswered might jeopardize your eligibility for the program. 1. 2. Name Last Address Number City 3. 5. Phone ( ) 6. Date of Birth State 4. E-mail 7. Age Street Zip Code First Middle

Gender Male Female

8. * Social Security Number: *Required by the U.S. Department of Education reporting purpose only. Information will remain confidential* 9. 10. What is the primary language spoken at home? Race/Ethnicity (optional): African American Caucasian 11. Are you a U.S. citizen? Permanent Resident Other 12. 15. 16. High School Guidance Counselors Name Are you applying to or are you involved in any other academic programs? Yes No (If yes, please explain) Asian/American Hispanic Yes Native American Other

No (If no, indicate status below) Permanent Registration Card Number 13. Grade 14. School ID #

17.

Are you involved in sports or extracurricular activities? (If yes, please explain and provide as much information as possible)

Yes No

Section 1. Student Information (Continuation)

UConn Upward Bound/ConnCAP Program-2011 Student Application

18. STUDENT SELF-ASSESSMENT Please note that this section is used to determine your eligibility for the program and whether or not you need the academic services offered during the summer and academic year components. The information that you will provide here will be used only to give you the services that will meet your academic and personal needs. a. What is your current grade average: A B C D F

b. What type of courses are you taking? Honors College Preparatory General Mix c. In what areas do you need tutoring, assistance or more information to prepare you for college? Please check all the ones that apply to you: English Composition and Grammar Writing Essays Reading Skills Mathematics (please be specific) Science (please be specific) Foreign Language (please be specific) Improving test scores Basic Computer Skills Study Skills (note taking, test preparation, time management, etc) Preparation for the Connecticut Academic Performance Test (CAPT) PSAT/SAT preparation Motivation to study Motivation to stay in school Motivation to go to college School attendance Developing social/communication skills Need more information about colleges Need more information about careers 19. STUDENT STATEMENT: Explain why you would like to be in the Upward Bound/ConnCAP Program and what you hope to gain by participating in this program. Use additional paper if needed.

Section 2. Parents Information* *Parental information is required to determine students eligibility. If the student does not live with either parent, please explain and provide the requested information.
THIS SECTION MUST BE COMPLETED.
UConn Upward Bound/ConnCAP Program-2011 Student Application

ALL INFORMATION PROVIDED IS CONFIDENTIAL WE ARE REQUIRED TO OBTAIN INCOME INFORMATION AND DOCUMENTATION IN ORDER TO MEET FEDERAL AND STATE FUNDING GUIDELINES 1. 2. 3. 5. 7. 8. 9. Mothers Name Address Number Home Phone Number Occupation Income Before Taxes Street City/State 4. Work Phone Number 6. Employer Yearly Weekly Bi-weekly (Check One) No Zip Code

Have you (mother or guardian) graduated from a four-year college/university? Yes If yes, give name of college or university Fathers Name Number Street City/State 12. Work Phone Number 14. Employer Yearly Weekly Bi-weekly (Check One) Yes

10. Address Zip Code 11. Home Phone Number 13. Occupation 15. Income Before Taxes

16. Have you (father or guardian) graduated from a four-year college/university? If yes, give name of college or university

No

17. List all members of the household. Do not include parents or guardians. Include student applicant. Name Age Relationship School Grade

Section 2. Parents Information (Continuation)

THIS SECTION MUST BE COMPLETED. ALL INFORMATION PROVIDED IS CONFIDENTIAL AND WILL BE USED ONLY TO DETERMINE STUDENTS ELIGIBILITY IN THE PROGRAM. WE ARE REQUIRED TO OBTAIN INCOME INFORMATION AND DOCUMENTATION IN ORDER TO MEET FEDERAL AND STATE FUNDING GUIDELINES
UConn Upward Bound/ConnCAP Program-2011 Student Application

Does your household receive assistance from any of the following sources? Free or Reduced School Lunch Yes Aid to Families with Dependent Children Yes No No

*If your family receives a major portion of its annual income from one of these benefit sources, please attach a copy of a check stub or a summary statement. Social Security Veterans Benefits Food Stamps Unemployment Compensation Other Yes Yes Yes Yes Yes No No No No No Yes No

Did you file (or going to file) an income tax form for 2010? TOTAL NUMBER OF PEOPLE LIVING IN HOUSEHOLD: MOST RECENT HOUSEHOLD TAXABLE INCOME:

PLEASE INCLUDE IN THIS APPLICATION A COPY OF YOUR INCOME TAX FORMS. IF YOU HAVE NOT FILED YET, A COPY WILL BE REQUESTED LATER ON. WE ARE REQUIRED TO OBTAIN THIS INFORMATION FOR OUR STUDENT FILES ONLY. I certify that all statements in this application are true to the best of my knowledge and understanding. Any misleading information can be cause for student dismissal. ***Signature of Parent/Guardian: Date:

IF YOU ARE NOT PLANNING TO FILE INCOME TAX, PLEASE COMPLETE THE FOLLOWING FOR TAX YEAR 2010 (documentation of income will be requested): WAGES, SALARIES, OR TIPS BUSINESS, FARM INCOME OTHER NON-TAXABLE INCOME (DISABILITY, AFDC, VETERAN BENEFITS, RETIREMENT, UNEMPLOYMENT) $ $ $

I certify that all statements in this application are true to the best of my knowledge and understanding. Any misleading information can be cause for student dismissal. ***Signature of Parent/Guardian: Date:

UNIVERSITY OF CONNECTICUT Upward Bound/ConnCAP Program 2011 Student Application

Section 3. Program Required Forms

UConn Upward Bound/ConnCAP Program-2011 Student Application

Report Cards/Transcript Release Form

Transcript/Records: The Upward Bound/ConnCAP Program often requests high school report cards and college transcripts in order to monitor students academic progress and to meet state and federal guidelines. We need your permission to request these documents from the appropriate high schools and colleges/universities. This information is used for assessment and reporting purposes. PARENT/GUARDIAN STATEMENT I hereby grant permission for the release of my childs high school records, transcripts, and all other achievement records to the University of Connecticut Upward Bound/ConnCAP Program. Date Students Name (please print) Students Signature

Date

Parent/Guardians Name (please print) Parent/Guardian Signature

Please Note: The personal information required above is confidential and protected by the Privacy Act. Only authorized Upward Bound/ConnCAP Program staff and U.S. Federal and State Department of Education personnel will see the information. It is necessary to maintain accurate data. Your cooperation is appreciated.

UConn Upward Bound/ConnCAP Program-2011 Student Application

UNIVERSITY OF CONNECTICUT Upward Bound/ConnCAP Program 2011 Student Application

Section 3. Recommendation Forms Teacher Recommendation Form

Students Name Class Student: Teacher: Please fill in the above information and give this form to your English, Science or Math teacher. This applicant is seeking admission to the University of Connecticut Upward Bound/ConnCAP Program. We appreciate any information you could provide to assist us in judging the applicants academic potential for post-secondary education and/or academic needs. Please complete and return this form to the student or guidance counselor named above. Thank you for your Teachers Name

cooperation. 1. How would you rate this applicant as compared to other students you have taught with in regard to the following? Below Average Motivation Self-Discipline Growth Potential 2. Please check on the following services/skill development that you think the applicant needs: English Composition and Grammar Writing Essays Reading Skills Improving test scores Homework completion Study Skills (note taking, test preparation, time management, etc): Preparation for the Connecticut Academic Performance Test (CAPT) PSAT/SAT preparation Motivation to study Motivation to stay in school Motivation to go to college Class attendance Developing social/communication skills Other: 3. Please add any further comments that will help us to evaluate the above candidate. Average Good Excellent

__________________________________ Teachers signature

____________________________ Date

Please return this form to the student or mail to: UConn Upward Bound/ConnCAP Program, U-2170, Storrs, CT 06269

UNIVERSITY OF CONNECTICUT
UConn Upward Bound/ConnCAP Program-2011 Student Application

Upward Bound/ConnCAP Program 2011 Student Application

Section 3. Recommendation Forms Guidance Counselor or Designated School Staff Recommendation Form
Students Name Student School ID # Guidance Counselor: The above student applicant is seeking admission to the University of Connecticut Upward Bound/ConnCAP Program. We appreciate any information you could provide to assist us in judging the applicants academic potential for post-secondary education and/or academic needs. Please attach the students most recent report card and CMT test scores). Thank you for your cooperation. 1. How would you rate this applicant as compared to other students you have worked with in regard to the following? Below Average Motivation Self-Discipline Growth Potential 2. Please check on the following services/skill development that you think the applicant needs: College readiness (moving to college preparatory classes, taking higher math or science courses) Improving test scores Basic Computer Skills General study skills (note taking, test preparation, time management, etc) Preparation for the Connecticut Academic Performance Test (CAPT) PSAT/SAT preparation Motivation to study Motivation to stay in school Motivation to go to college School attendance Developing social/communication skills Need more information about colleges Need more information about careers Other (please be specific) 3. Please add any further comments that will help us to evaluate the above candidate. Average Good Excellent

__________________________________ Guidance Counselors/School Staff signature

____________________________ Date

Please return this form to the student or mail to: UConn Upward Bound/ConnCAP Program, U-2170, Storrs, CT 06269

UConn Upward Bound/ConnCAP Program-2011 Student Application